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The Risks and Benefits of Home-Centered Deliveries in America.

Posted on | January 1, 2016 | No Comments

db144_fig1CDC, 1990-2012

Mike Magee

In the final week of 2015, there was a great deal of coverage on the relative risks of home delivery versus hospital-based delivery in the United States. The coverage derived from a NEJM study of Oregon databases in 2012 and 2013 that listed the intended site for delivery for all births for the first time. This allowed for a comparison of deaths rates and Apgar scores. The study was augmented in this week’s NEJM with a case study and an editorial.

The issue is a complicated one, made no more discernible by comparisons to the UK obstetrics approach, which more heavily emphasizes home deliveries, but also maintains a higher level of integration between out-of-hospital and in-hospital systems. Translation: they are better prepared to support their home based program and better able to access hospital settings for emergent problems should they arise during a home delivery.

At the core of the debate are the risk/benefit profiles of these two very different settings for delivery. What are the facts as we know them?

1. Thirty five years ago, the risk of death at hospital delivery for a single baby was approximately 1 in a thousand, and the Caesarean rate was 15%. Today, the risk is roughly the same, and the U.S. Caesarean rate has more than doubled.

2. In the current study of Oregon women in 2012 and 2013, the Caesarean rate of women who had chosen home-delivery as their primary option was 5.3%. For women who chose hospital delivery, it was 24.7%.

3. The Oregon study included 75,923 planned and completed hospital deliveries, 1968 completed home births, and 1235 completed free-standing birth-center deliveries. Unplanned home births were excluded and only singleton, term, normally developed fetuses in cephalic presentation were included in the analysis.

4. Comparisons of fetal death were based on “intended site” of delivery, not on where the delivery actually took place. Thus, a labor that began at home and ran into trouble requiring emergency transfer to the hospital fell into the “at-home” category.

5. Comparing those who intended a home delivery with those who intended hospital delivery, there was a statistically significant higher rate of fetal death in the at-home group – 1.8 per 1000 for planned hospital births versus 3.9 per 1000 for planned out-of-hospital births. That risk was conuter-balanced by risks associated with the more than four-fold increase in C-section rates among women chosing a hospital-based birth.

6. Approximately 16% of women who intend a home-based birth require emergency transport to a hospital.

7. Wilbur’s NEJM case study succinctly summarizes the complex pro’s and con’s for those chosing home deliveries with these words: “Cesarean delivery imposes substantial risk, including a rate of serious maternal complications and death that is three times as high as the rate with vaginal delivery, even among low-risk women. In addition, one in four women giving birth in a hospital report feeling overwhelmed, frightened, or anxious. The consistent, one-on-one support of a home-birth attendant and the familiar environment of the home may improve the experience for some women. However, even in the patient who is at lowest risk, unpredictable events can occur during labor, and immediate access to an operating room and a neonatal resuscitation team could improve outcomes.”

Where is there consensus? All parties appear to agree that their are risks and benefits to both approaches. For the U.S., that likely means the growth of hybrid models and a better trained and accessible goup of home-based birth support professionals as well as greater integration (as exists in the UK) to allow emmergency access to hospital settings if required.

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